Family history and disease outcomes in patients with Crohn’s disease:A comparison between China and the United States

AIM To investigate the differences in family history of inflammatory bowel disease(IBD) and clinical outcomes among individuals with Crohn’s disease(CD) residing in China and the United States.METHODS We performed a survey-based cross-sectional study of participants with CD recruited from China and the United States.We compared the prevalence of IBD family history and history of ileal involvement,CD-related surgeries and IBD medications in China and the United States,adjusting for potential confounders.RESULTS We recruited 49 participants from China and 145 from the United States.The prevalence of family history of IBD was significantly lower in China compared with the United States(China:4.1%,United States:39.3%).The three most commonly affected types of relatives were cousin,sibling,and parent in the United States compared with child and sibling in China.Ileal involvement(China:63.3%,United States:63.5%) and surgery for CD(China:51.0%,United States:49.7%) were nearly equivalent in the two countries.CONCLUSION The lower prevalence of familial clustering of IBD in China may suggest that the etiology of CD is less attributed to genetic background or a family-shared environment compared with the United States.Despite the potential difference in etiology,surgery and ileal involvement were similar in the two countries.Examining the changes in family history during the continuing rise in IBD may provide further insight into the etiology of CD.     

Impact of medical therapy on patients with Crohn’s disease requiring surgical resection

AIM: To evaluate the impact of medical therapy on Crohn’s disease patients undergoing their first surgical resection.METHODS: We retrospectively evaluated all patients with Crohn’s disease undergoing their first surgical resection between years 1995 to 2000 and 2005 to 2010 at a tertiary academic hospital (St. Paul’s Hospital, Vancouver, Canada). Patients were identified from hospital administrative database using the International Classification of Diseases 9 codes. Patients’ hospital and available outpatient clinic records were independently reviewed and pertinent data were extracted. We explored relationships among time from disease diagnosis to surgery, patient phenotypes, medication usage, length of small bowel resected, surgical complications, and duration of hospital stay.RESULTS: Total of 199 patients were included; 85 from years 1995 to 2000 (cohort A) and 114 from years 2005 to 2010 (cohort B). Compared to cohort A, cohort B had more patients on immunomodulators (cohort A vs cohort B: 21.4% vs 56.1%, P < 0.0001) and less patients on 5-aminosalysilic acid (53.6% vs 29.8%, P = 0.001). There was a shift from inflammatory to stricturing and penetrating phenotypes (B1/B2/B3 38.8% vs 12.3%, 31.8% vs 45.6%, 29.4% vs 42.1%, P < 0.0001). Both groups had similar median time to surgery. Within cohort B, 38 patients (33.3%) received anti-tumor necrosis factor (TNF) agent. No patient in cohort A was exposed to anti-TNF agent. Compared to patients not on anti-TNF agent, ones exposed were younger at diagnosis (anti-TNF vs without anti-TNF: A1/A2/A3 39.5% vs 11.8%, 50% vs 73.7%, 10.5% vs 14.5%, P = 0.003) and had longer median time to surgery (90 mo vs 48 mo, P = 0.02). Combination therapy further extended median time to surgery. Using time-dependent multivariate Cox proportional hazard model, patients who were treated with anti-TNF agents had a significantly higher risk to surgery (adjusted hazard ratio 3.57, 95%CI: 1.98-6.44, P < 0.0001) compared to those without while controlling for gender, disease phenotype, smoking status, and immunomodulator use.CONCLUSION: Significant changes in patient phenotypes and medication exposures were observed between the two surgical cohorts separated by a decade.     

Surgical recurrence in Crohn’s disease: a comparison between different types of bowel resections

Purpose

To compare recurrence frequency and location between different types of bowel resections in Crohn’s disease patients.

Methods

This was a retrospective study of consecutive patients undergoing bowel resection for Crohn’s disease between 2006 and 2016. Type of primary operation was recorded and grouped as ileocolic resection, small bowel resection, segmental colon resection with colocolic anastomosis or colorectal anastomosis, colectomy with ileorectal anastomosis, or end stoma operation. Binary logistic regression was used to compare surgical recurrence frequency between groups. We also investigated how Crohn’s disease location at reoperations was related to the primary bowel resection type.

Results

Altogether, 218 patients with a median follow-up of 4.7 years were included in our study. Reoperation was performed in 42 (19.3%) patients. The risk of reoperation using the ileocolic resection group as reference was the following: small bowel resection (odds ratio (OR) 2.95, 95% confidence interval (CI) 1.01–8.66; P?=?0.049), segmental colon resection with colocolic or colorectal anastomosis (OR 6.20, 95% CI 2.04–18.87; P?=?0.001), colectomy with ileorectal anastomosis (OR 26.57, 95% CI 2.59–273.01; P?=?0.006), and end stoma operation (OR 4.62, 95% CI 1.90–11.26; P?=?0.001). In case of surgical recurrence, the reoperation type and location correlated with the primary bowel resection type.

Conclusions

Reoperation frequency in Crohn’s disease is lower after ileocolic resection than after other types of bowel resections. Surgical recurrence in Crohn’s disease tends to maintain the disease location of the primary operation. One third of Crohn’s patients undergoing an end stoma operation will still need new bowel resections due to recurrence.

     

Short and long-term outcomes of endoscopic balloon dilatation for Crohn’s disease strictures

AIM:To investigate the short and long-term outcomes of endoscopic balloon dilatation(EBD) for Crohn’s disease(CD) strictures.METHODS:Between January 1995 and December 2011,47 EBD procedures were performed in 30 patients(8 females and 22 males) with CD.All patients had strictures through which an endoscope could not pass,and symptoms of these strictures included abdominal pain,abdominal fullness,nausea,and/or vomiting.The 47 strictures included 17 anastomotic and 30 de novo strictures.Endoscopy and dilatation were performed under conscious sedation with intravenous diazepam or flunitrazepam.The dilatations were all performed using through-the-scope balloons with diameters from 8 mm to 20 mm on inflation and lengths of 30-80 mm.Each dilatation session consisted of two to four,3-min multistep inflations of the balloon,repeated at intervals of 1 wk until adequate dilatation(up to 15-20 mm in diameter) was achieved.The follow-up data were collected from medical records and analyzed retrospectively.Primary success was defined as passage of the scope through the stricture after EBD.Longterm outcomes were analyzed focusing on interventionfree survival and surgery-free survival demonstrated by the Kaplan-Meier method.(Intervention-free meant cases in which neither endoscopic balloon re-dilatation nor surgery was needed after the first dilatation during the observation period).The log rank test was used to evaluate the difference in long-term outcomes between anastomotic and de novo stricture cases.RESULTS:Primary success was achieved in 44 of the 47 strictures(93.6%).Balloon dilatations failed in 3 cases(6.4%).In 1 case,EBD was a technical failure because the guide-wire could not be passed through the stricture which showed severe adhesion and was a flexural lesion of the intestine.In 2 cases,unexpected perforations occurred immediately after balloon dilatation.Of the 47 treatments,complications occurred in 5(10.6%).All 5 patients had de novo strictures.One suffered bleeding,two high fever and there were colorectal per     

Optimizing perioperative Crohn’s disease management: Role of coordinated medical and surgical care

AIM: To investigate rates of re-establishing gastroenterology care, colonoscopy, and/or initiating me-dical therapy after Crohn’s disease(CD) surgery at a tertiary care referral center.METHODS: CD patients having small bowel or ileocolonic resections with a primary anastomosis between 2009-2012 were identified from a tertiary academic referral center. CD-specific features, medications, and surgical outcomes were abstracted from the medical record. The primary outcome measure was compliance rates with medical follow-up within 4 wk of hospital discharge and surveillance colonoscopy within 12 mo of surgery. RESULTS: Eighty-eight patients met study inclusion criteria with 92%(n = 81) of patients returning for surgical follow-up compared to only 41%(n = 36) of patients with documented gastroenterology follow-up within four-weeks of hospital discharge, P < 0.05. Factors associated with more timely postoperative medical follow-up included younger age, longer length of hospitalization, postoperative biologic use and academic center patients. In the study cohort, 75.0% of patients resumed medical therapy within 12 mo, whereas only 53.4% of patients underwent a colonoscopy within 12 mo of surgery.CONCLUSION: Our study highlights the need for coordinated CD multidisciplinary clinics and structured handoffs among providers to improve of quality of care in the postoperative setting.     

Helicobacterpylori infection and gastropathy： A comparison between Indonesian and Japanese patients

AIM: To compare the effects of Helicobacter pylori ( H pylori) infection on gastropathy between Indonesian and Japanese patients.METHODS: Biopsy specimens were obtained during upper gastrointestinal endoscopy from 167 subjects (125 Indonesians and 42 Japanese) with uninvestigated symptoms of dyspepsia. The specimens were analyzed for the presence of H pylori using urease analysis, histopathology, and cell culture. The grade and activity of gastritis was assessed using the updated Sydney system.RESULTS: The percentages of Indonesian and Japanese patients who were H pylori-positive at the antrum or body of the stomach were similar (68% and 59.5%, respectively; P = 0.316). Of those who were H pylori-positive, more Japanese patients than Indonesian patients had high levels of polymorphonuclear cells ( P = 0.001), mononuclear cells ( P = 0.013), glandular atrophy ( P = 0.000), and intestinal metaplasia ( P = 0.011) in both the antrum and body of the stomach.CONCLUSION: The grade of gastritis and prevalence of mucosal atrophy and intestinal metaplasia were higher in Japanese patients. The difference between Indonesian and Japanese patients was significant.     

Risk factors of surgical site infections in patients with Crohn’s disease complicated with gastrointestinal fistula

Purpose

Surgical site infection (SSI) is the most common complication following surgical procedures. This study aimed to determine risk factors associated with SSI in patients with Crohn’s disease (CD) complicated with gastrointestinal fistula.

Methods

This was a retrospective review of patients who underwent surgical resection in gastrointestinal fistula patients with CD between January 2013 and January 2015, identified from a prospectively maintained gastrointestinal fistula database. Demographic information, preoperative medication, intraoperative findings, and postoperative outcome data were collected. Univariate and multivariate analysis was carried out to assess possible risk factors for SSI.

Results

A total of 118 patients were identified, of whom 75.4% were men, the average age of the patients was 34.1 years, and the average body mass index (BMI) was 18.8 kg/m². The rate of SSI was 31.4%. On multivariate analysis, preoperative anemia (P = 0.001, OR 7.698, 95% CI 2.273–26.075), preoperative bacteria present in fistula tract (P = 0.029, OR 3.399, 95% CI 1.131–10.220), and preoperative enteral nutrition (EN) <3 months (P < 0.001, OR 11.531, 95% CI 3.086–43.079) were predictors of SSI. Notably, preoperative percutaneous abscess drainage was shown to exert protection against SSI in fistulizing CD (P = 0.037, OR 0.258, 95% CI 0.073–0.920).

Conclusion

Preoperative anemia, bacteria present in fistula tract, and preoperative EN <3 months significantly increased the risk of postoperative SSI in gastrointestinal fistula complicated with CD. Preoperative identification of these risk factors may assist in risk assessment and then to optimize preoperative preparation and perioperative care.

     

Treatment of perianal fistula and abscess: Crohn’s and non-Crohn’s

Opinion statement The management of perianal abscesses and fistulas is relatively straightforward in most cases and based on a sound knowledge of the anatomy of the anorectum and adherence to established medical and surgical principles. Asymptomatic fistulas should not be treated, whereas abscesses require surgical drainage under general anesthesia. Fistula treatment includes drainage of any associated sepsis and eradication of the fistula track to prevent recurrence while preserving sphincter integrity. A small percentage of anal abscesses and fistulas are complex and very challenging to manage, particularly in conditions such as rectovaginal fistulas and abscesses and/or fistulas complicating Crohn’s disease. Treatment strategies in these situations rely on an accurate clinical assessment of the degree of rectal inflammation and perianal pathology. Treatment should combine aggressive medical therapy (antibiotics, immunomodulators, and anti-tumor necrosis factor antibody treatment) and minimal surgical interventions. Patients with proctitis have a significantly lower healing rate and a significantly higher complication rate with aggressive surgical interventions.     

Clinical features and oncological outcomes of intestinal cancers associated with ulcerative colitis and Crohn’s disease

Journal of Gastroenterology - Patients with longstanding inflammatory bowel disease are at high risk of developing intestinal cancers. In this study, we aimed to elucidate the differences between...     

Long-term success rate after surgical treatment of anorectal and rectovaginal fistulas in Crohn’s disease

Background  Due to the considerable variety in the clinical presentation of anorectal and rectovaginal fistulas in Crohn’s disease, data on treatment results for each type of fistula are limited. The aim of this study was to summarize the results after surgical treatment of such fistulas in a large consecutive series of patients. Patients and methods  All patients with anorectal or rectovaginal fistula due to Crohn’s disease requiring surgery in our institution between 1991 and 2001 were extracted from a prospective database. A standardized telephone interview was conducted and patients were followed in our outpatient clinic, the department of internal medicine, or at their gastroenterologist. Type of fistula and interventions were classified and analyzed. Recurrence-free time intervals were estimated for each type of fistula and for the different surgical procedures. The influence of the surgical procedure, the number of operations performed, and the correlation to other localizations of the disease were analyzed in regard to the recurrence rate. Results  From 777 patients with Crohn’s disease undergoing surgery between 1991 and 2001, 147 had anorectal or rectovaginal fistula (292 operations). Ninety-eight percent of them also had Crohn’s disease in the colon or rectum compared to only 21% of patients without a fistula (p value <0.001). Over long-term follow-up, 29 patients (20%) required proctectomy. Submucosal fistulas needed major surgery in only 14% of cases compared to 56% of cases with rectovaginal fistulas. After 5 years, complex fistulas showed a strong trend towards a higher recurrence rate after surgery than simple submucosal fistulas (45.6% vs. 18.8%, p = 0.079). Whereas recurrences occurred over the whole observation period in the group of patients with complex fistulas, there was no further recurrence in patients with submucosal fistulas 13 months after surgery. In rectovaginal fistulas, additional levatorplasty showed no advantage over standard endorectal advancement flap. Conclusions  Long-term follow-up demonstrates that recurrence rates after repair of complex fistulas for Crohn’s disease are high and continuously increase over time. Submucosal fistulas have the best outcome; after 13 months without recurrence, definite cure can be expected.     

Rifaximin and Crohn’s disease

In a recent article,Longman and Swaminath analyzed our paper on the use of rifaximin in patients with moderately active Crohn’s disease(CD).Here we report some considerations concerning their article.The exploratory post-hoc subgroup analysis showed that early-stage disease and,differently from that written by Longman and Swaminath,also colonic involvement seemed to be associated with a significant higher efficacy of rifaximin-EIR 800 mg twice daily.Early-stage disease is generally considered as the more easily treatable phase of CD,and the better response to rifaximin in Crohn’s colitis is in accordance with the high concentration of bacteria in the colon.In addition,patients with C reactive protein level>5 mg/L achieved remission more significantly than patients with normal values,thus suggesting that the symptoms were probably caused by inflammation instead of by non-inflammatory causes.We also analyze the role of rifaximin against gut bacteria and the clinical situations that could obtain the best results from antibiotics.     

Time between suspected and confirmed diagnoses of Crohn’s disease and ulcerative colitis in patients followed in gastroenterological practices in Germany

Aims

The goal of the present study was to analyze the time between suspected and confirmed diagnoses of Crohn’s disease (CD) and ulcerative colitis (UC) in patients followed in gastroenterological practices in Germany.

Methods

The study included individuals who received a suspected diagnosis of CD or UC (index date) and were followed in 47 gastroenterological practices in Germany between January 2007 and December 2016. The main outcome measure of the study was the time between suspected and confirmed diagnoses of CD and UC. Covariables included age, sex, and type of health insurance (private or statutory). A multivariate linear regression model was used to analyze the impact of the different variables on the time between suspected and confirmed diagnoses of CD and UC.

Results

The study included 2657 patients with a suspected diagnosis of CD and UC between 2007 and 2016. The mean age was 39.7 (SD 15.9) and 41.3 (16.8) in the CD and UC groups, respectively. Median time between suspected and confirmed diagnoses was 46 days in the CD group and 43 days in the UC group. Median time ranged from 8 to 112 days in the different gastroenterology practices and was significantly shorter in individuals with private health insurance coverage than in those with statutory health insurance.

Conclusions

Median time between suspected and confirmed diagnoses of CD or UC was around 45 days in patients followed in gastroenterological practices in Germany. Health insurance was the only factor to have a significant impact on this time.

     

A cross-sectional study of 130 Brazilian patients with Crohn’s disease and ulcerative colitis: analysis of articular and ophthalmologic manifestations

This is a cross-sectional study that analyzed the pattern and frequency of articular and ophthalmologic manifestations in patients with Crohn’s disease (CD) and ulcerative colitis (UC), with or without signs of active bowel inflammation. One hundred and thirty consecutive patients with CD (n = 71) and UC (n = 59) were examined. Simple X-rays of lumbar spine, sacroiliac joints, and calcaneal bone were performed and human leukocyte antigen (HLA)-B27 was typed. Joint manifestations occurred in 41 (31.5%) patients, 27 (38%) with CD and 14 (23.7%) with UC. Peripheral involvement occurred in 22 patients, axial involvement in five, and mixed involvement in 14. The most frequently involved joints were knees (56.1%), ankles (29.3%), and hips (29.3%), while the predominant pattern was oligoarticular (84.6%) and asymmetrical (65.6%). Enthesitis was identified in seven (5.4%) patients and inflammatory lumbar pain in 13 (10%). Eight of these patients fulfilled the diagnostic criteria for ankylosing spondylitis (6.2%). Radiographic sacroiliitis occurred in 12 patients (9.2%). Ocular abnormalities were present in six patients (6.2%), and HLA-B27 was positive in five (5.8%). In conclusion, the articular manifestations in the present study were predominantly oligoarticular and asymmetric, with a low frequency of ophthalmologic involvement and positive HLA-B27.     

Takayasu’s arteritis: clinical features and outcomes of 125 patients in China

Takayasu’s arteritis (TA) is a chronic inflammation that frequently involves the aorta and its major branches. The clinical features of TA vary in different ethnic populations. The objective of this study is to characterize the clinical features, angiographic findings, and response to treatment of patients with TA in Changhai Hospital, Shanghai, China. The hospital records of 125 patients diagnosed with TA were retrospectively evaluated. Eighty patients were followed for a median duration of 36 months. Females (86.4%) were most frequently affected. The mean age at onset was 26.9 years. Constitutional symptoms were present in only 38.4% of patients. The most common clinical finding was pulse deficit. Histological findings from 12 clinically inactive patients showed active lesions in 58.3%. Angiographic classification showed that type I was the most common, followed by type V and IV. Type I was more common in adult patients than in pediatric patients. Although immunosuppressive treatment induced remission in most patients, over 90% of those who achieved later remission relapsed. Both bypass procedures and angioplasty showed high rates of initial success, but restenosis occurred in 34.7% of bypass procedures and 77.3% of angioplasty procedures. Eight patients died during the follow-up period with the main cause of death being congestive heart failure. Constitutional symptoms were not frequent in our study. Correlation between the clinical assessment of disease activity and histologic findings is often poor in TA. Angiographic findings showed that type I was the most common in our study. Over the longer term, the outcomes of revascularization were superior to angioplasty.     

Hyperhomocysteinemia in patients with Crohn’s disease

Background

Thromboembolic complications have been reported in patients with Crohn’s disease. Among the contributing factors, hyperhomocysteinemia has been described, although controversial data exist. The aim of our study was to assess the incidence of hyperhomocysteinemia in a nonselected group of patients with Crohn’s disease and to determine whether it might represent a risk marker for thrombosis in such patients.

Methods

Fifty consecutive patients were recruited, and clinical and laboratory variables were compared between those without and those with hyperhomocysteinemia. In the latter, gene mutations in N5-N10-methyltetrahydrofolate reductase were searched for, and clinical and laboratory variables were related to hyperhomocysteinemia. The presence/absence of thrombotic episodes in both groups was determined.

Results

Both groups had similar clinically active disease, with higher C-reactive protein values found in those with hyperhomocysteinemia. Hyperhomocysteinemia was found in 46 % of patients. Of these, 74 % had moderate, 13 % intermediate, and 13 % severe increase in serum homocysteine levels. No relationship was found between homocysteine levels, and age, vitamin B12 levels, folic acid levels, Crohn’s Disease Activity Index score, and CRP values. Gene mutations were found in 5 (22 %) patients, 2 homozygotes and 3 heterozygotes. None of the patients with or without hyperhomocysteinemia had episodes of venous or arterial thrombosis, or stroke.

Conclusions

Hyperhomocysteinemia is frequent in patients with Crohn’s disease, and it could be a cofactor for the pathogenesis of thrombotic episodes.     

Partnership-Level Analysis of African American Women’s Risky Sexual Behavior in Main and Non-Main Partnerships

The majority of research on risky sexual behavior in African American women has examined global associations between individual-level predictors and behavior. However, this method obscures the potentially significant impact of the specific relationship or relationship partner on risky sexual behavior. To address this gap, we conducted partnership-level analysis of risky sexual behavior among 718 African American women recruited from HIV counseling, testing, and referral sites in four states. Using mixed model regressions, we tested relationships between condomless vaginal intercourse with men and variables drawn from the Theory of Planned Behavior, Theory of Gender and Power, and previous research specifically on sexual risks among African American women. Significant associations with risky sexual behavior indicate the need for continued emphasis on condom attitudes, condom negotiation behaviors, and overcoming partner resistance to condoms within both main and non-main partnerships when implementing interventions designed to address HIV and sexually transmitted infection risks among African American women.